Capability · Revenue Integrity
Denial architecture, rejection-code discipline, and mid-cycle CDI redesign for hospitals and health systems.
Hospitals spent an estimated $19.7 billion in 2022 on denial appeals and $43 billion in 2025 chasing payments insurers already owed. The FY2025 Medicare fee-for-service improper payment rate reached 6.55%, or $28.83 billion. Denials are not a payer problem. Denials are the visible symptom of a coding, documentation, and workflow architecture that is silently failing every day.
What we redesign
Registration, eligibility, and authorization workflow. The place where 85% of avoidable denials are actually born, before a chart ever reaches coding.
Clinical documentation improvement, coding accuracy, and DRG assignment integrity. Medicare Advantage denials rose from 17.4% in 2020 to 32.0% in 2024; DRG downgrades are the most damaging class because they never trigger a denial alert.
Appeals architecture, payer-audit defense, and reconciliation workflow. HHS OIG found MA plans overturned 95% of appealed prior-auth denials for SNF admission, evidence that most initial denials are wrong on the merits.
The Foreign Medical Program processed only 37% of claims within 45 days against a 90% goal in FY2024, per GAO. For international hospital operators serving U.S. veterans, this is not a footnote. It is the operational architecture that determines whether veteran care is a revenue channel or a cost sink.
Our founder's public record includes leading FMP revenue integrity programs. Public references route through GAO's report and the VA program page; specific engagements are covered in past-performance briefings under appropriate confidentiality.
The revenue-integrity operating model
A four-to-six-week map of denial root causes across the front-end, mid-cycle, and back-end functions. The output is a denial-taxonomy that reveals which upstream architecture choice caused which downstream denial pattern.
Prioritized rebuild plan with explicit ROI targets. AI is applied where it earns its keep. McKinsey's public estimate is 30 to 60% cost-to-collect reduction for touchless RCM automation.
Continuous coaching for the CDI, coding, and appeals teams. Denial rates and DRG-downgrade rates decline as architecture solidifies, not as staff work harder.
Every workflow decision, every escalation, every appeal, documented at the standard payer audits, CMS reviewers, and OIG demand.
Adjacent capabilities
AI-enabled RCM, predictive staffing, and touchless workflow architecture.
Data-quality initiatives and assessments across clinical and administrative sources.
SDVOSB set-aside strategy, teaming architecture, and past-performance packaging.
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